Healthcare Provider Details

I. General information

NPI: 1508467853
Provider Name (Legal Business Name): ULTIMATE CARE SUPPORTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 10/14/2023
Certification Date: 10/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 E MAIN ST STE 100
COLUMBUS OH
43213-2580
US

IV. Provider business mailing address

2020 BRICE RD STE 235
REYNOLDSBURG OH
43068-3464
US

V. Phone/Fax

Practice location:
  • Phone: 614-868-3821
  • Fax: 614-868-3921
Mailing address:
  • Phone: 614-868-3821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: MR. SAMUEL BRAIMA
Title or Position: PRESIDENT
Credential:
Phone: 614-868-3821